Doctoring Heroes into Villains.

There is no quick source for an objective truth: none of us are deeply read on all topics at all times, and none of us has time to fact-check everything we hear. So our perception is our reality, and in a junk-food mass-media world, reality can be created in just 140 characters. This has not gone unnoticed.

Call it spin, call it PR, call it propaganda; the same story twisted in violently different directions according to whichever audience is being pandered to, or for whatever objective is the goal. Apple is pro-terrorist for refusing to decrypt an iPhone/Apple is a champion of privacy. Meddling Eurocrats force pointless laws on the UK/Over 50% of UK exports are to the EU, which are subject to EU laws regardless of membership. Censorship is necessary to protect our children/censorship violates free speech, and so democracy. Trump isn’t afraid to tell it how he sees it/Trump is a bigoted demagogue.

In isolation, the exaggerated polarity of these points isn’t clear. Even side-by-side, both angles appear to have merit. It’s only when advocates of a position are challenged (usually by facts, logic, or inconsistencies) that we glimpse their falsity. When we see this we must pause to consider whether the belief is sincerely held, or if it is merely a marvelous sleight of hand to achieve some unseen goal.

With great power, comes great irresponsibility.

This case study would be fascinating if it weren’t tragic. The UK government is running a PR campaign against some of the most highly-educated, trusted professionals, who are dedicated to helping society: our doctors.

First, some background: The government made an election pledge to implement a ‘truly’ 7-day National Health Service (currently there is 7-day emergency and urgent care, but limited elective services on weekends).

A key piece of this puzzle is renegotiating the doctor contracts, which began in late 2013. A year later, the British Medical Association — negotiating for the doctors — announced that talks had stalled, “because of inadequate safeguards against excessive working hours”. The government wants the existing workforce and existing budget to staff the extended service — i.e. the same staff, spread thinner, with no extra money. Doctors already regularly work exhausting shift patterns, including 90-hour weeks, 13-hour shifts, and 7 consecutive nights — and fatigued doctors are dangerous for patients.

By extending weekend services, the number of patients increases. If the number of staff are kept the same, either existing weekday services must be scaled back (which is dangerous for patients), or the existing workforce must work longer hours (which is dangerous for patients).

“The BMA has been clear in its support for better seven-day services, but the Government needs to be clear about what an expansion of services will look like and, crucially, how it can be safely staffed and resourced, without existing services being scaled back. Doctors already work around the clock, 24/7, so the existing contract is not a roadblock to seven-day services.”

Today it is 18 months later. There were more negotiations, but no progress was made on the BMA’s primary concerns around safety for patients, and safety for doctors. The government has stepped away from the negotiations, and has taken the position to impose the contract. This has resulted in several partial-walkout doctor strikes since January — the first in 40 years — and unless the government returns to the negotiating table in the next few weeks, we are about to have the first full-walkout strikes in UK history.

The government’s Public Accounts Committee scrutinised the Department of Health’s plans in February. They were bewildered by the DoHs lack of even a ballpark understanding of the impact their ‘truly’ 7-day NHS will have.

“I’m surprised you can put this policy into place without having some idea of the implication for staffing levels at the headcount planning level, or the cost/budget… It’s interesting that the Secretary of State and the department went out and imposed a contract on the junior doctors when there are real gaps on your long term planning for staffing. It seems like you’re flying blind.”

(Note: A ‘junior’ doctor is a qualified, practicing doctor who is not yet a consultant or a GP. In other words, they’re a ‘doctor’)

The government has chosen not to spend their resources working out these details, which would provide the exact reassurances the BMA has been asking for for at least 18 months: “the detail, evidence and modelling on the changes they want to introduce… This includes detail on what additional services they want to make available, how much they will cost to deliver, and guarantees on what support services need to be in place to provide them safety”.

Instead, they have chosen the bizarre option of a negative PR campaign.

“The public should not delay accessing services if they need them. However, there is clear independent clinical evidence that standards of care are not uniform across the week and this Government makes no apology for tackling the problem to make sure all patients receive the same high quality care seven days a week.”

Clearly a little collateral damage is OK in ruthless pursuit of the greater good.

Let’s look at some of the other spin weapons the government is using (we’ll come back to the “clear independent clinical evidence”).

Shift The Debate.

How have they done this? The current system of ‘unsocial hour’ pay banding protects doctors from working excessive hours by making it expensive for employers. So the government is technically correct — but it’s missing the point. The BMA have proposed alternative, cost-neutral safeguards, but these have been rejected.

The real beauty of this spin is the can of worms it opens: shifting the debate on to pay has resulted in hundreds of column inches being written comparing doctors overall salaries with other professions, contrasting other jobs that work unsocial hours without pay premiums, and ultimately creating a forum that allows the doctors to be branded greedy, lazy, overpaid, etc.

Remember: Doctors did not ask for a pay rise, and already work weekends.

Assume Unproven Truths.

Let’s get back to the “clear independent clinical evidence”: since publication 6 months ago, the government’s justification for the contract changes are almost exclusively because, in the words of the Health Secretary, “according to an independent study conducted by The BMJ, there are 11,000 excess deaths because we do not staff our hospitals properly at weekends”.

“It is not possible to ascertain the extent to which these excess deaths may be preventable; to assume that they are avoidable would be rash and misleading.”

The Editor of The BMJ has registered her concern about “the way in which you have publicly misrepresented an academic article published in The BMJ”. The UK Statistics Authority has asked that “future references to this article are clear about the difference between implying a causality that the article does not demonstrate, and describing conclusions reached by authors”. The Prime Minister was confronted in Parliament that the Department of Health was misrepresenting the statistics. He responded by Avoiding The Question.

Perhaps the reason the government refuses to acknowledge this correction, and instead continue to cite the study as justification for the contract imposition, is because it is such a powerful tool for Appealing To Emotion.

Appeal To Emotion.

You see this one any time intrusive laws are introduced in the name of ‘defending us from terrorists’, or ‘protecting children from paedophiles’. This logical fallacy is characterized by the manipulation of emotions, usually to disguise an absence of factual evidence (see Assume Unproven Truths). When done well, the lack of a direct causal link can be missed, and the audience finds themselves agreeing that whatever needs to be done must be done.

We’ve already seen this with the scaremongering of weekend deaths (strangely, that news article was published the same day that the study was published, which must mean one of the UK’s most reviled trash tabloids was given early access to The BMJ’s research). The government even doubled-down on this approach, singling out a specific condition that elicits strong emotional responses from many of us: stroke victims, they said, are more likely to die on weekends, as a result of staffing levels. Despite pleas from stroke specialists that the highly publicised untrue statements were leading patients to defer seeking treatment and coming to unnecessary further harm, the Prime Minister himself repeated the claims. A month later, one of the co-authors of the cited paper commented on a blog that “we have never looked at junior doctor staffing in any of our papers, and have never claimed to”.

On the 13th November 2015, a series of coordinated terrorist attacks were carried out in Paris. Barely missing a beat, on the 19th November the Medical Director of NHS England, Sir Bruce Keogh, published an emotive letter asking for assurances that striking doctors would return to work in the event of a terror attack. Emails later surfaced proving that the letter was written in collaboration with the government, who advised Sir Bruce that “the more hard-edged you can be on this, the better”.

One last example. The strikes themselves are, naturally, an easy target for the government to claim the moral high-ground and stir up some fear in the general population, e.g. “the action taken by the BMA will inevitably put patients in harm’s way”. They offer no reassurance that junior doctors’ roles will be filled by senior consultants during the strikes, so patients are likely to be in safer hands. In fact during the New Zealand junior doctors strike of 2006, senior doctors demonstrated (predictably) that they could carry the workload of at least two junior doctors, and both waiting times and length of stay were reduced by about 50% in the Emergency Department.

Appear Reasonable.

This is a tough one: how does one of the least trusted professions appear reasonable next to one of the most trusted professions, who also happen to be some of the sharpest scientific minds our education system produces?

First, Appeal To Authority. We’ve already met Sir Bruce Keogh, who the government relies on for an “independent clinical” view. He co-authored two of the eight papers the government (mis-)uses to justify their 7-day NHS plans. Several months after publication, The BMJ were forced to declare a ‘conflict of interest’ to the ‘11,000 deaths’ paper, that Sir Bruce is a “long standing proponent of improving NHS services seven days a week”. Despite demonstrating his lack of independence (and ethics) through his outrageous terrorist threat letter, the press continue to call him “NHS’s top doctor”. The press also fails to recognise the irony of a man who has done so much to undermine the trustworthiness of the profession, making a statement that the strikes are “unethical” and will “irreparably damage” trust in the profession.

When the government announced that they were withdrawing from negotiations and were imposing the contract, they did it armed with a letter brimming with NHS managerial authority, advising the government “to do whatever it deems necessary”:

I can confirm that this position is supported by both the NHS Confederation and NHS Providers, together with support from Chief Executives across the country, and their names are supplied.

Another approach to Appear Reasonable is to make your opponent appear less reasonable. The Department of Health frequently publicly claims that they secured agreement on ‘90%’ of the negotiated issues, and that the BMA “refuses to discuss the remaining 10% that is not agreed” (the original unsocial hour pay safeguards issue from 18 months ago). Fascinatingly, this DoH spokesman — Ben Gummer — reveals that “Many of the issues settled within the contract were not requested by the BMA” — if you want to turn 0% agreed into 90% agreed, just keep adding non-issues to the table!

(This particular exchange with Ben Gummer is a goldmine for examples, so bear with me the next few paragraphs.)

He goes on to explain “The fact is that the contract will be fairer and safer — better for patients and better for doctors” (Assume Unproven Truths), and when questioned, he repeatedly Avoids The Question by challenging opposition MPs to “condemn” the strikes, “because this is about emergency cover for patients” (Appeal To Emotion). He ignores the Patients Association’s condemnation that “The Government’s decision to impose contract terms on junior doctors is unacceptable… It is clear that the acrimonious dispute… is unnecessary and damaging”. He ignores the plea from 160 health and care charities who “are calling on government to drop the imposition of a new contract”.

He attempts to undermine the BMA’s mandate, stating “most junior doctors will say, ‘This is not something I went into medicine to do’”, ignoring that 98% of doctors who voted backed strike action (28,305 doctors; a 76% turnout). He claims “fewer than half have been turning out for industrial action”, while not clarifying that he’s including doctors who were not eligible to strike, such as those working in emergency care. He claims that the doctors have been “misled” by the “militant” BMA, insulting both the union officials and the doctors, all of whom are highly trained in critical analysis.

If you were still wondering which side of the fence Ben sits, his expert medical opinion of the strike action (he has a history degree) is that it is “highly irresponsible”, “disproportionate, ill-judged, unnecessary and wrong”.

I’ll finish with Ben’s magnum opus of Appearing Reasonable, which he recited to Parliament to justify imposition. It is almost too exhausting to read:

Time and again, the Government have implored the BMA to return to talks. Time and again, the Government have extended deadlines. Time and again, the Government have listened and responded to the BMA’s concerns, making agreed changes to the proposed contract. The Government have provided every possible means to ensure productive talks. We have charged the most experienced negotiators in the NHS to work with the BMA. At our invitation, we have discussed the contract at ACAS not once, but twice. We have asked one of the most respected chief executives in the service, Sir David Dalton, to attempt to reach a solution. Yet, despite all this, the BMA has set itself against talks, refusing to negotiate on the few remaining points of contention, even though it had previously promised to discuss them.

The NHS is the sum of all the dedicated, brilliant staff working within it, and they are under attack. Public support continues to be strong, but the forthcoming escalated strikes will rock this, and the spin machine will be quick to focus on and amplify any misstep by the doctors. The doctors themselves are exhausted by all the politics, and are devastated that they have been forced into a position where they have to choose between the short-term consequences of their withdrawal of care, and the entire future of the NHS.

They are not greedy, militant, radicalised, lazy; they dedicate their lives to saving lives, taking on more responsibility than most of us can imagine. Encumbered with an absolute respect for the truth, and a compulsion to do what’s best for their patients, they are practically unarmed against an opponent who shares neither of these virtues.

Please support the junior doctors to stop the government imposing an unfair, unsafe contract which risks the safe staffing of our hospitals and surgeries. Join the social media campaign. Write to your MP and local newspaper. Donate to the #JustHealth team’s legal challenge of the contract imposition. Or just give a tired doctor a thumbs-up on the bus — it will make a bigger difference than you think.